Functional outcomes and complications after surgical repair of triceps tendon rupture

Rehabilitation following distal triceps repair: A scoping review

BACKGROUND

Distal triceps ruptures are relatively rare injuries where surgical repair is recommended for return to function and sport. There are various fixation techniques and different therapy protocols described in the literature.

PURPOSE

To scope and critically evaluate current knowledge of post-operative protocols and complications following repair and extrapolate tendon healing principles to clinical practice.

STUDY DESIGN

Scoping review.

METHODS

The Joanna Briggs Institute framework for Scoping Reviews was followed, and specific inclusion/exclusion criteria were applied to identify high-quality, relevant evidence. Studies were included if they met the following criteria: written in English, focused on adults over 17 years of age with complete distal triceps tendon ruptures, and published as peer-reviewed articles, conference abstracts, university dissertations, or theses. Additionally, the studies had to use at least one validated outcome measure. Electronic and manual searches were completed of published and gray literature. Quantitative sources were included for complete triceps ruptures that measured outcomes using at least one validated outcome measure. Qualitative sources that were published within 10 years from a reputable journal were included for qualitative synthesis.

RESULTS

Eighteen quantitative articles consisting of case series and systematic reviews, and 16 expert opinion and narrative reviews met the inclusion criteria. There was no standardized postoperative protocol with differences found in timing for ranging, strengthening, and return to function. The most reported complications were tendon rerupture, infection, pain, and ulnar nerve neuropathy.

CONCLUSIONS

What is known about triceps tendon repairs comes from low level evidence. Randomized controlled trials are required to evaluate the effect of surgical constructs and therapy on function. The protocols identified in this scoping review typically progressed through several stages, starting with complete immobilization and moving on to ranging, strengthening, and finally returning to sport and functional activities. Therapists can apply general tendon healing principles when rehabilitating these patients and should be aware of modifiers to healing timeframes when making decisions on strengthening and resuming activities that require high function.

Triceps Tendon Reattachment Using Mini Plates and Screws After Failure of Olecranon Avulsion Fracture Fixation in Osteoporotic Bone: A Case Report

This is a case report of an 85-year-old woman with osteopenia who underwent olecranon avulsion fracture repair with supplemental triceps tendon repair following a fall on an outstretched arm. The initial procedure failed due to osteoporotic bone quality and an atraumatic disruption of the olecranon fracture fixation. The patient subsequently underwent further surgical intervention with an olecranon avulsion fracture excision and a novel triceps tendon repair technique using plate augmentation and fiber tape. Surgeons may consider this novel approach as an initial treatment for elderly patients with osteopenia or osteoporosis undergoing olecranon avulsion fracture fixation, to prevent the failure and consequent revision surgery.

Return to Work, Sport, and Sport- Related Activity After Distal Triceps Tendon Repair: A Systematic Review

BACKGROUND

Distal triceps tendon injuries are relatively rare injuries, often occurring in highly active patients with physically demanding jobs or lifestyles. Information on return to work, sport, and activity is essential for patient education and counseling after a distal triceps tendon rupture.

PURPOSE

To determine the rates of return to work, sport, and sport-related activity after distal triceps tendon repair.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

PubMed, CINAHL, MEDLINE, Web of Science, and SPORTDiscus were queried from the earliest record through January 12, 2024. Articles were included if they examined return to various activities (exercise, sport, work, or military duty) after distal triceps tendon repair. Data on return to sport/work/activity were collected as well as information on patient satisfaction, pre-existing medical history or medication use (ie, anabolic steroids or corticosteroids), and complications. Article quality was assessed via the Methodological Index for Non-Randomized Studies (MINORS) scale.

RESULTS

Of 164 articles initially retrieved, 10 retrospective studies were included. Patients (n = 318; 74.2% male, 25.8% female) who underwent distal triceps tendon repair had a mean age of 44.7 ± 5.5 years with a mean follow-up time of 52.6 ± 21.4 months. After distal triceps tendon repair, 93.3% of patients (112/120) returned to sport, 95.3% (81/85) returned to military duty, and 92.6% (100/108) returned to work. Of the studies that evaluated satisfaction, the majority of patients reported high satisfaction after surgery. The overall complication rate (ranging from persistent pain and wound complications to nerve injuries and reruptures) after distal triceps tendon repair was 18.0%, the rerupture rate (complete and partial) was 7.2%, and the reoperation rate was 3.9%, with all partial reruptures undergoing nonoperative care.

CONCLUSION

A distal triceps tendon rupture is a rare but potentially challenging injury, traditionally occurring in an active population, and often requires surgical repair. Importantly, >90% of an active-duty military population, athletes, and the general workforce was able to return to sport or their respective activity after surgery. Furthermore, there was high patient satisfaction and low rates of complications and reoperations after distal triceps tendon repair.

Postoperative Rehabilitation and Return-to-Sport Criteria After Distal Triceps Rupture Repair: A Scoping Review

Background

Distal triceps rupture is a rare injury that is commonly surgically repaired to improve elbow strength and function. Most patients are active and have goals to return to specific activities and sports. There is no gold standard rehabilitation protocol for return to sport (RTS) after distal triceps repair.

Purpose

To identify in the literature any criteria used for RTS after distal triceps repair.

Study Design

Scoping review; Level of evidence, 4.

Methods

Under PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, level 1 to 4 studies that examined distal triceps repair and had a minimum follow-up duration of 12 months were deemed eligible for study inclusion. Exclusion criteria encompassed studies that employed nonoperative treatment, lacked specific RTS criteria, or involved revision cases. The selected studies underwent assessment regarding RTS outcomes, timelines, rates, and methodological quality.

Results

Of the initial 378 unique studies, 6 studies (including 116 patients involved in 16 different sports) met the inclusion criteria. Four of the studies reported RTS rates, with a mean of 89.3%. The duration of time for returning to sport was reported in 2 studies and varied from 4 to 6 months. The parameters most emphasized in the rehabilitation protocols were progressive range of motion exercises, followed by early immobilization and progressive strengthening exercises. Supervised therapy was reported in only 2 (33%) studies. Although all studies included a rehabilitation protocol and 5 studies included a timeline for RTS, only 1 study provided subjective criteria, and no studies utilized specific objective measurement criteria. The overall study quality was fair.

Conclusion

This review demonstrated that the overall RTS rate after distal triceps repair was high (89.3%), with no consensus on RTS criteria. Most studies included initial immobilization followed by progressive range of motion and strengthening. Timing after surgery was used as a measure to RTS in the minority of studies and varied between 4 and 6 months. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols.

Distal Triceps Tendon Repair in Strength Athletes Leads to Satisfactory Return to Sports: A Retrospective Analysis of 22 Cases

Background: Distal triceps brachii tendon rupture (DTTR) is a relatively rare injury that is common in bodybuilding and high-intensity contact sports and can lead to significant functional impairment of the elbow joint. This study was conducted to evaluate clinical outcomes and the rate of return to sports among competitive bodybuilders and high-demand strength athletes after surgical repair of DTTR. Methods: This retrospective case series was performed in an institutional setting in tertiary health care. Return to sports of 22 competing or high-demand strength athletes (meaning three or more exercises per week) were analyzed pre- and postoperatively after surgical repair of DTTR using a hybrid technique of transosseous sutures and anchor fixation. Descriptive statistics were used to analyze demographic variables, and independent and paired t-tests were used to assess clinical outcomes. Results: The follow-up showed that from pre- to postoperatively, there was no deterioration in the number of sports disciplines (2.4 and 2.5 sporting activities per person, respectively; p = 0.540) or in the frequency of weekly training (4.1 and 4.1 times per person, respectively; p = 0.329). The postoperative visual analog scale for pain (from 6.0 to 1.6, p < 0.001), level of fitness (from 5.1 to 2.6, p = 0.002), and ability to train (from 5.2 to 1.3, p < 0.001) improved significantly. The time of return to sports was 1.5-3 months and 4-6 months after the surgery for ten patients each. The overall rate of return to sports was 95%, whereas 86% returned to the preinjury level of sporting activity. Conclusions: Repair of DTTR leads to high rates of return to sports in competitive athletes.

Triceps brachii insertional footprint: Under-estimated complexity

Background

The detailed complexity of triceps brachii insertional footprint continues to challenge surgeons as evidenced by continued reports of triceps-associated complications following elbow procedures. The purpose of this study is to describe the three-dimensional footprint of the triceps brachii at its olecranon insertion at the elbow.

Methods

22 cadaveric elbows were dissected leaving only the distal insertion of the triceps intact. The insertion was defined and probed with a three-dimensional digitizer to create a digital three-dimensional footprint allowing width, height, and surface area of the footprint to be recorded relative to the bare area. The insertional soft tissues of tendon versus muscle along with the shape of the footprints were qualitatively described.

Results

The mean width and surface area of the lateral segment was greater in males than in females (30.07 mm vs. 24.37 mm, p  =  0.0339 and 282.1 mm vs. 211. 56 mm, p  =  0.0181, respectively). No other statistically significant differences between the sexes were noted. The triceps insertional footprint was "crescent-shaped" and consisted of three regions: central tendon, medial muscular extension, and lateral muscular extension.

Discussion

These findings can help explain the importance of avoiding these muscular structures during triceps-off approaches and provides the framework for future clinical studies. Clinical Relevance: Basic Science, anatomy study, cadaver dissection.

Return to Sport Following Distal Triceps Repair

PURPOSE

The purpose of this investigation was to examine the timeline of return-to-sport following distal triceps repair; evaluate the degree of participation and function upon returning to sport; and identify risk factors for failure to return to sport.

METHODS

Patients who underwent distal triceps repair with a minimum of 1 year of follow-up were retrospectively reviewed. Patients completed a subjective sports questionnaire and were scored on a visual analog scale for pain; the Mayo Elbow Performance Index; the Quick Disabilities of the Arm, Shoulder, and Hand; and the Single Assessment Numerical Evaluation.

RESULTS

Out of 113 eligible patients who had a distal triceps repair, 81 patients (71.7%) were contacted. Sixty-eight patients (84.0%) who participated in sports prior to surgery were included at 6.0 ± 4.0 years after surgery, and the average age was 46.6 ± 11.5 years. Sixty-one patients (89.7%) resumed playing at least 1 sport by 5.9 ± 4.4 months following distal triceps repair. However, 18 patients (29.5%) returned to a lower level of activity intensity. The average postoperative Quick Disabilities of the Arm, Shoulder, and Hand; Mayo Elbow Performance; visual analog scale for pain; and Single Assessment Numerical Evaluation scores were 8.2 ± 14.0, 89.5 ± 13.4, 2.0 ± 1.7, and 82.2 ± 24.3, respectively. No patients underwent revision surgery at the time of final follow-up.

CONCLUSIONS

Distal triceps repair enables 89.7% of patients to return to sport by 5.9 ± 4.4 months following surgery. However, 29.5% of patients were unable to return to their preinjury level of activity. It is imperative that patients are appropriately educated to manage postoperative expectations regarding sport participation following distal triceps repair.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Surgical treatment of distal triceps tendon ruptures]

OBJECTIVE

Restoration of the anatomy and the original length of the muscle-tendon unit in triceps tendon ruptures.

INDICATIONS

Acute and chronic triceps tendon ruptures with persisting symptoms and significant strength deficits.

CONTRAINDICATIONS

Infections and tumors in the surgical area.

SURGICAL TECHNIQUE

Prone position. Skin incision over the distal triceps in a lateral direction around the olecranon. Mobilization of the tendon and débridement of the olecranon. Drilling of 2 × 2.9 mm suture anchor holes medial and lateral into the footprint of the olecranon. In addition, drilling through the olecranon 12 mm distal to the tip of the olecranon and transosseous introduction of 4 sutures. Then the suture anchors (all-suture or titanium anchors) are inserted into the drill holes. Refix the deep and superficial tendons with the anchor threads. Refix the upper tendon portions with the transosseous sutures. In the case of chronic lesions, a graft interposition is necessary.

POSTOPERATIVE MANAGEMENT

Dorsal 10 ° splint, then change to an orthosis fixed in 20 ° extension and passive mobility 0-30 ° flexion for 6 weeks. From the 7th week onwards, load-free, physiotherapeutically controlled increasing mobilization. Starting weight-loading from the 13th week on. Full load after 6 months.

RESULTS

In all, 34 male strength athletes with acute triceps tendon rupture underwent surgery using the hybrid technique described and were prospectively recorded. The MEPS‑G score averaged 94.7 points, there were no permanent limitations in mobility, and the postoperative strength ability averaged 94% of the original strength performance ability. The return to sport achieved 100%. The complication rate was 20.6%. Reconstruction of the distal triceps tendon using hybrid technology leads to very good functional results. Half of all patients complained of symptoms even before the rupture, which suggests previous damage to the distal triceps tendon caused by degeneration.

Complications after traumatic distal triceps tears: an analysis of 107 cases

Background

The major complication and reoperation rates after distal triceps repair are poorly defined. The purpose of this large retrospective cohort study of distal triceps repairs performed by multiple surgeons within a large orthopedic group was to more clearly define the rates and risk factors of clinically impactful major complications and reoperations.

Methods

All distal triceps tendon repairs for traumatic injuries performed from January 2006 to April 2017 with a minimum 2-month follow-up were identified using the Current Procedural Terminology code 24342. A total of 107 patients were included in this study. The primary outcome measure was total major complication rate. Reoperations, minor complications, and risk factors were also tracked.

Results

Repairs were performed via bone tunnels (63.5%), suture anchors (13%), or a combination of the two (17.8%). A 14% complication rate and 13.1% reoperation rate were observed. Indication for reoperation included 9 reruptures, 3 infections, and 2 others. The time between injury and surgery was not found to be a risk factor for tendon rerupture. Smoking status, gender, utilization of a splint or controlled motion brace, and time to first active mobilization were not shown to influence rates or rerupture.

Conclusion

Distal triceps repair for traumatic injuries is associated with 14% complication and 13.1% reoperation rates. Patient, rehabilitation, and surgeon-specific factors did not influence the complication rate.

Surgical repair of distal triceps rupture: a systematic review of outcomes and complications

Background

Triceps tendon injury is rare and accounts for only 2% of all tendinous injuries. It typically occurs after trauma or physical strain with eccentric loading. Treatment involves surgical repair, commonly with either transosseous bone tunnels or suture anchors. Nonsurgical management is typically reserved for low-demand or high-risk patients, as this is associated with deficits in strength and functional disability. Despite several recent high-quality observational studies that have added to our understanding of outcomes after surgical repair, we are not aware of a systematic review that includes literature published after 2015. In addition, prior reviews did not compare outcomes between different surgical repair methods, particularly transosseous bone tunnel and suture anchor techniques.

Methods

This systematic review examines published literature between January 1970 and May 2021 in PubMed, Scopus, and Cochrane databases to further examine reported functional outcomes and compare those outcomes between the two surgical repair methods.

Results

Our literature search yielded 309 results, of which only 16 met inclusion criteria. At the latest follow-up, the mean Disabilities of Arm, Shoulder, and Hand score was 4, the mean Quick Disabilities of Arm, Shoulder, and Hand score was 8, the mean Mayo Elbow Performance Score was 92, the mean American Shoulder and Elbow Surgeons-Elbow score was 99, the mean modified American Shoulder and Elbow Surgeons score was 94, the mean Oxford Elbow Score was 43, and the mean isokinetic muscle strength testing was 87%. A very high percentage (95%) of patients reported being satisfied with the repair. Preinjury levels of function were achieved in 92% of patients, and 100% regained at least a score of 4 of 5 for gross muscle strength. Complications occurred in 15% of cases, of which retears accounted for 5%. Subanalysis of cases with reported repair types revealed a significantly higher overall complication rate with transosseous repairs than with suture anchor repairs (18% vs. 8%, P = .008) as well as a higher retear rate in the transosseous repair group (7% vs. 2%, P = .03).

Conclusion

Patient-reported outcome measures were favorable for both suture anchor and transosseous tunnel repair methods. Suture anchor repair showed significantly better results with regard to isokinetic strength testing, complication rates, and retear rates. Further study is needed to establish superiority of either technique and cost-efficacy. In light of the evidence supporting greater biomechanical strength and lower clinical rates of failure, surgeons may consider use of a suture anchor technique for repair of distal triceps ruptures.

The surgical management of distal triceps tendon ruptures: a systematic review

BACKGROUND

Distal triceps tendon ruptures (DTTRs) are highly uncommon injuries and can be treated with surgical repair. The purpose of this review was to compare the outcomes and complications of various surgical techniques used for primary repair of DTTRs.

METHODS

The electronic databases MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed were searched from data inception to October 15, 2020. The Methodological Index for Non-randomized Studies tool was used to assess study quality. Data are presented descriptively.

RESULTS

A total of 19 studies were identified, comprising 560 patients (565 triceps tendons), of whom 78.6% were male patients. The mean age was 46.1 ± 8.4 years, and the mean follow-up period was 31.8 ± 21.0 months. The overall complication rate across all DTTR repair procedures was 14.9%. The distribution of complications for each technique was 29.2% for the direct repair technique, 15.2% for the transosseous technique (transosseous suture), and 7.7% for the suture anchor technique. Common complications include ulnar neuropathies, infections, and pain. The overall rerupture rate for transosseous suture, suture anchor, and direct repair was 4.3% (n = 12), 2.1% (n = 3), and 0% (n = 0), respectively. Patients undergoing DTTR repair experience significant improvements postoperatively regarding pain, strength, and range of motion.

CONCLUSIONS

Patients undergoing DTTR experience improvements in postoperative outcomes; however, there is a moderate reported risk of rerupture or complication. Owing to the heterogeneity in rupture patterns, surgical procedures, and outcome measures, it is difficult to ascertain the superiority of one surgical technique over another. Future studies should use large prospective cohorts and long-term follow-up to determine more accurate complication rates and outcome scores.

[Lesions of the triceps tendon : Diagnostics, management, treatment]

The triceps brachii muscle is the main extender of the elbow joint. Triceps tendon rupture or tearing presents a rare injury pattern in general. Distal tendon ruptures occur most commonly in the area of the insertion of the olecranon. Fractures of the radial head are reported as the most common concomitant injury. In many cases, pre-existing degenerative damage predisposes for tendon injury. These include local steroid injections, anabolic steroid abuse, renal insufficiency requiring dialysis, hyperparathyroidism, lupus erythematosus and Marfan's syndrome. However, the most frequent trauma mechanism is a direct fall onto the extended forearm or a blow to the elbow. Beside clinical examination and sonography, magnetic resonance imaging is the diagnostic gold standard. The treatment of triceps tendon injuries includes conservative as well as operative approaches, whereby the indications for surgical treatment must be generously considered depending on the patient's age, functional demands of the patient, involvement of the dominant extremity as well as on the extent of the tendon rupture.

Bone suture anchor repair and functional outcome of a triceps tendon rupture, a rare clinical entity

Triceps tendon rupture is rare and easily missed on presentation. A 58-year-old man was seen in our accident and emergency department with an inability to extend his right elbow against gravity after he fell. Ultrasound and MRI confirmed the suspected diagnosis of a traumatic triceps tendon rupture and excluded additional injuries. Surgical repair was carried out by a bone anchor suture reinsertion of the tendon to the olecranon. After 2 weeks of cast immobilisation, an early active range of motion (ROM) rehabilitation schedule was followed, resulting in excellent elbow function at 12 weeks postoperatively.In conclusion, it is important to suspect this rare injury and use additional studies to confirm the diagnosis of triceps tendon rupture. Also, good clinical outcome with regards to function can be achieved using bone anchor suture repair and an early active ROM rehabilitation schedule.

Return to work following distal triceps repair

PURPOSE

The purpose of this study was to evaluate the rate and duration of return to work in patients undergoing distal triceps repair (DTR).

METHODS

Consecutive patients undergoing DTR from 2009 to 2017 at our institution were retrospectively reviewed at a minimum of 1 year postoperatively. Patients completed a standardized and validated work questionnaire; a visual analog scale for pain; the Mayo Elbow Performance Score; the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and a satisfaction survey.

RESULTS

Of 113 eligible patients who underwent DTR, 81 (71.7%) were contacted. Of these patients, 74 (91.4%) were employed within 3 years prior to surgery (mean age, 46.0 ± 10.7 years; mean follow-up, 5.9 ± 3.9 years). Sixty-nine patients (93.2%) returned to work by 2.2 ± 3.2 months postoperatively. Sixty-six patients (89.2%) were able to return to the same level of occupational intensity. Patients who held sedentary-, light-, medium-, and high-intensity occupations were able to return to work at a rate of 100.0%, 100.0%, 80.0%, and 76.9%, respectively, by 0.3 ± 0.5 months, 1.8 ± 1.5 months, 2.5 ± 3.6 months, and 4.8 ± 3.9 months, respectively, postoperatively. Of the workers' compensation patients, 15 (75%) returned to work by 6.5 ± 4.3 months postoperatively, whereas 100% of non-workers' compensation patients returned to work by 1.1 ± 1.6 months (P < .001). Seventy-one patients (95.9%) were at least somewhat satisfied, with 50 patients (67.6%) reporting excellent satisfaction. Seventy-two patients (97.3%) would undergo the operation again if presented the opportunity. A single patient (1.4%) required revision DTR.

CONCLUSIONS

Approximately 93% of patients who underwent DTR returned to work by 2.2 ± 3.2 months postoperatively. Patients with higher-intensity occupations had an equivalent rate of return to work but took longer to return to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

Clinical Outcomes of Low-Cost, Anchorless Repair of the Triceps Tendon Using a Proximal Knot Technique

Purpose

To use validated outcome measures to evaluate the clinical results of surgical repair of distal triceps tendon ruptures using transosseous tunnels and high-strength sutures with proximally based knots.

Methods

A consecutive series of traumatic distal triceps tendon ruptures at a single institution was studied. All cases were surgically repaired by 1 surgeon using high-strength suture with a bone tunnel-based repair technique. Repair knots were oriented proximally instead of in the traditional distal position. All patients were evaluated at long-term follow-up with a physical examination performed by the orthopaedic surgeon and the following validated outcome measures: Disabilities of the Arm, Shoulder and Hand score; Mayo Elbow Performance Score; and visual analog scale score.

Results

Seven male patients with a mean age of 38 years (range, 19-50 years) and mean follow-up period of 4.1 ± 1.2 years underwent distal triceps tendon repair with bone tunnels and high-strength sutures with proximally positioned knots. Of the repairs, 4 involved the dominant arm. At final follow-up, the mean Disabilities of the Arm, Shoulder and Hand score was 1.3 ± 3.1; the mean Mayo Elbow Performance Score was 99.3 ± 1.9; and the mean visual analog scale score was 0. One additional patient who declined participation in the study had wound dehiscence and infection with an associated partial rerupture.

Conclusions

This case series of triceps tendon repairs using transosseous tunnels and proximally based knots showed favorable postoperative elbow function based on validated outcome measures.

Level of Evidence

Level IV, therapeutic case series.

Triceps Tendon Ruptures: Risk Factors, Treatment, and Rehabilitation

Triceps tendon ruptures (TTRs) are rare and often occur as a result of falling on an outstretched hand, forceful eccentric contraction, direct trauma to the elbow, or lifting against resistance. TTRs are most commonly seen in middle-aged men, football players, and weightlifters. Radiography, ultrasonography, and magnetic resonance imaging may be utilized for diagnosis and to guide treatment. Acute partial TTRs may have good outcomes with nonoperative management. Surgery should be considered if nonoperative treatment is unsuccessful or if substantial musculotendinous retraction is present. Surgical repair is strongly recommended for complete TTRs.

Acute Triceps Tendon Repair: A Technique Utilizing 3 Curved Tunnels and Proximal Knots

Although triceps tendon tears are less common than other tendon tears, complete ruptures require surgical repair to restore the strength of the extensor mechanism of the elbow. There are several described techniques for repair using both transosseous tunnels and suture anchors. Current techniques often result in large suture knots over the dorsal ulna under thin subcutaneous tissue, which can be irritating for patients. Knotless techniques require costly suture anchors. In this technical note, we describe a novel transosseous 3-tunnel technique with proximal suture knots to lessen the potential for postoperative pain.

Surgical Repair of Distal Triceps Tendon Injuries: Short-term to Midterm Clinical Outcomes and Risk Factors for Perioperative Complications

Background

Few large-scale series have described functional outcomes after distal triceps tendon repair. Predictors for operative success and a comparative analysis of surgical techniques are limited in the reported literature.

Purpose

To evaluate short-term to midterm functional outcomes after distal triceps tendon repair in a broad patient population and to comparatively evaluate patient-reported outcomes in patients with and without pre-existing olecranon enthesopathy while also assessing for modifiable risk factors associated with adverse patient outcomes and/or revision surgery.

Study Design

Case series; Level of evidence, 4.

Methods

This study was a retrospective analysis of 69 consecutive patients who underwent surgical repair of distal triceps tendon injuries at a single institution. Demographic information, time from injury to surgery, mechanism of injury, extent of the tear, pre-existing enthesopathy, perioperative complications, and validated patient-reported outcome scores were included in the analysis. Patients with a minimum of 1-year follow-up were included.

Results

The most common mechanisms of injury were direct elbow trauma (44.9%), extension/lifting exercises (20.3%), overuse (17.4%), and hyperflexion or hyperextension (17.4%). Eighteen patients were identified with pre-existing symptomatic enthesopathy, and 51 tears were caused by an acute injury. A total of 36 complete and 33 partial tendon tears were identified. Bone tunnels were most commonly used (n = 30; 43.5%), while direct sutures (n = 23; 33.3%) and suture anchors (n = 13; 18.8%) were also used. Perioperative complications occurred in 21.7% of patients, but no patients experienced a rerupture at the time of final follow-up. No statistically significant relationship was found between patient age (P = .750), degree of the tear (P = .613), or surgical technique employed (P = .608) and the presence of perioperative complications.

Conclusion

Despite the heightened risk of perioperative complications after primary repair of distal triceps tendon injuries, the current series found favorable functional outcomes and no cases of reruptures at short-term to midterm follow-up. Furthermore, age, surgical technique, extent of the tear, and mechanism of injury were not associated with adverse patient outcomes in this investigation. Pre-existing triceps enthesopathy was shown to be associated with increased complication rates.

Outcomes of Triceps Rupture in the US Military: Minimum 2-Year Follow-up

BACKGROUND

The objective of this study was to examine the subjective and objective midterm functional clinical outcomes of surgically repaired triceps injuries in a moderate- to high-demand population.

METHODS

The US Military Health System was queried to identify all surgically treated triceps tendon ruptures between 2008 and 2013. Primary endpoints included rates of rerupture, perioperative complications, or significant persistent elbow dysfunction; Disability of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow score, and ability to do push-ups were also extracted.

RESULTS

Thirty-seven patients underwent triceps tendon repair with a mean follow-up of 49.8 ± 17.3 months (range: 26.8-80.2). The most common mechanisms of injury were military duties (27%), sporting activity (24%), or fall-related (21.6%), with most injuries occurring during an eccentric movement (54%). While 45% experienced occasional elbow pain postoperatively, only 1 patient (2.7%) had a rerupture. Despite this, at 2 years, 31 patients (84%) were able to return to full military duty. While 6 patients were discharged from military service, only 1 underwent medical separation while 5 retired for reasons unrelated to their triceps tendon rupture. Patient-reported outcomes were available for 14 patients at final follow-up. The average DASH and Mayo Elbow scores were 4.7 (SD ± 4.7, range: 0-15.9) and 85.4 (SD ± 11.7, range: 60-100), respectively. The cohort could perform mean 54.2 (range: 9-90) push-ups. In additional, 12 of 14 (85.7%) were satisfied with their elbow function.

CONCLUSIONS

The active duty cohort experienced excellent postoperative results with a high rate of return to military duty, despite nearly half of the patients recognizing some degree of activity-related, elbow pain.

Distal triceps transosseous cruciate versus suture anchor repair using equal constructs: a biomechanical comparison

BACKGROUND/HYPOTHESIS

Suture anchor-based repair has been advocated for repair of distal triceps avulsion, but previous models have used an unequal number of sutures across the repair site. We hypothesized that there would be no difference in triceps tendon displacement between gold standard repair with transosseous cruciate bone tunnels and suture anchor repair with an equal number of sutures in the constructs.

METHODS

The triceps tendon footprint was measured in 20 cadaveric elbows (10 matched pairs), and a distal triceps tendon rupture was created. The specimens in each pair were randomly assigned to transosseous cruciate repair or knotless, double-row, anatomic footprint, suture anchor repair. Specimens underwent cyclic loading to 1500 cycles and then load to failure. Footprint uncoverage was measured at 1500 cycles. Data for medial and lateral triceps tendon displacement, footprint uncoverage, and failure load were obtained.

RESULTS

Triceps displacement did not differ significantly between the transosseous cruciate and the suture anchor repair group at 1500 cycles on the medial (3.6 ±  0.9 mm vs. 4.3 ± 1.6 mm [mean ± standard deviation], respectively; P = .27) and lateral side (3.1 ± 1.2 mm vs. 2.0 ± 1.2 mm, respectively; P = .06). No other differences were found between the constructs.

DISCUSSION/CONCLUSION

Transosseous cruciate distal triceps repair and knotless double-row suture anchor repair using constructs with an equal number of sutures showed no significant difference in tendon displacement at 1500 loading cycles. These findings suggest that the biomechanical strength of an all-suture construct is not different from that of suture anchors for repair of distal triceps avulsions.

Results of primary repair of distal triceps tendon ruptures in a general population: a multicentre study

Aims

The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population.

Patients and Methods

A total of 28 patients were operated on for primary DTTR reinsertions, including 21 male patients and seven female patients with a mean age of 45 years (14 to 76). Of these patients, 23 sustained an acute DTTR and five had a chronic injury. One patient had a non-simultaneous bilateral DTTR. Seven patients had DTTR-associated ipsilateral fracture or dislocation. Comorbidities were present in four patients. Surgical treatment included transosseous and suture-anchors reinsertion in 22 and seven DTTRs, respectively. The clinical evaluation was performed using Mayo Elbow Performance Score (MEPS), the modified American Shoulder and Elbow Surgeons Score (m-ASES), the Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), and the Medical Research Council (MRC) Scale.

Results

A total of 27 patients (28 DTTRs) were available for review at a mean of 47.5 months (12 to 204). The mean MEPS, QuickDASH, and m-ASES scores were 94 (60 to 100), 10 (0 to 52), and 94 (58 to 100), respectively. Satisfactory results were observed in 26 cases (93%). Muscle strength was 5/5 and 4/5 in 18 and ten DTTRs, respectively. One patient with chronic renal failure experienced a traumatic rerupture of distal triceps. One patient (1 DTTR) experienced mild elbow stiffness.

Conclusion

Primary repair of acute and chronic DTTRs in a general population yields satisfactory results in the majority of patients with a low rerupture rate. Cite this article: Bone Joint J 2018;100-B:610-16.

Comparison of isometric triceps brachii force measurement in different elbow positions

PURPOSE

Objective and reliable force measurement is necessary to monitor the rehabilitation after triceps brachii pathology, injuries, and posterior approach-based surgery. It is unclear at which amount of extension the triceps is best tested and if comparison to the uninjured sided is reliable. This study aims to identify the most reliable elbow position at which elbow extension force is measured using a dynamometer. Furthermore, it aims to compare the extension strength of the dominant arm with that of the nondominant arm.

METHODS

Isometric elbow extension force of the dominant and nondominant arms of healthy subjects was measured. The measurements were taken in three sequences per arm in 0, 30, 60, 90, and 120 degrees of flexion. A subgroup repeated the measurements to analyze test-retest reliability using intraclass correlation.

RESULTS

We included a total of 176 volunteers. The repeated measures analysis of variance for within-subject effect showed the lowest variation coefficient at 30 degrees of flexion. Extension forces showed a mean difference of 3.2-6.9 N in advantage of the dominant arm, resulting in ratios from 1.05 to 1.09. Learning curve analysis showed that during the first session in dominant and nondominant arms, less forces were exerted.

CONCLUSION

The most reliable isometric triceps brachii muscle strength measurement was at 30 degrees of flexion of the elbow. Considering the learning curve, a first tryout session for both arms is indicated. Then, a second measurement suffices as no further learning curve is observed.

Operative Management of Acute Triceps Tendon Ruptures: Review of 184 Cases

BACKGROUND

Distal triceps tendon ruptures are rare. The authors present a series of 184 surgically treated, acute, traumatic triceps tendon avulsions and compare the complications between those treated with anchors (A) versus transosseous (TO) suture repair.

HYPOTHESIS

No difference exists in the retear rate between TO and A repairs. Study Designed: Cohort study; Level of evidence, 3.

METHODS

All patients who underwent an open primary repair of a traumatic triceps tendon avulsion within 90 days of injury, between 2007 and 2015, were retrospectively reviewed. Surgeries were performed within a multisurgeon (75 surgeons), multicenter (14 centers), community-based integrated health care system. Patient demographic information, type of repair, complications, and time from surgery to release from medical care were recorded.

RESULTS

184 triceps tears in 181 patients met the inclusion criteria. The mean age was 49 years (range, 15-83 years). There were 169 males. The most common mechanisms of injury were fall (56.5%) and weight lifting (19%). Mean time from injury to surgery was 19 days (range, 1-90 days); in 74.5% of cases, surgery was performed in 3 weeks or less. There were 105 TO and 73 A repairs. No significant difference was found between the two groups in the mean age ( P = .18), sex ( P = .51), completeness of tears ( P = .74), tourniquet time ( P = .455), and prevalence of smokers ( P = .64). Significant differences were noted between TO and A repairs in terms of reruptures (6.7% vs 0%, respectively; P = .0244), overall reoperation rate (9.5% vs 1.4%; P = .026), and release from medical care (4.3 vs 3.4 months; P = .0014), but no difference was seen in infection rate (3.8% vs 0%; P = .092). No difference was noted in release from medical care in patients who underwent surgery 3 weeks or less after injury compared with those undergoing surgery more than 3 weeks after injury (3.90 vs 4.09 months, respectively; P = .911).

CONCLUSION

Primary repair of triceps ruptures with TO fixation has a significantly higher rerupture rate, higher reoperation rate, and longer release from medical care than does repair with A fixation. Implementation of suture anchors in triceps repairs offers a lower complication rate and earlier release from medical care.

Triceps Tendon Anatomic Repair Utilizing the "Suture Bridge" Technique

Triceps tendon ruptures are uncommon injuries, but they typically require surgical repair. Multiple primary repair techniques are available, including transosseous, suture anchor, and anatomic repairs. The technique described here, the "suture bridge" repair, provides an anatomic repair of the distal triceps tendon to its footprint. It has the potential advantages of increased load to failure, better footprint coverage, higher load resistance, and allows for early motion.

Functional outcomes of distal triceps tendon repair comparing transosseous bone tunnels with suture anchor constructs

BACKGROUND

Distal triceps tendon ruptures are relatively rare. Few studies have investigated functional outcomes after repair. There is no consensus on fixation methods for this injury. The purpose of this study was to compare the functional outcomes and the reoperation rates after distal triceps tendon repairs using transosseous tunnels and suture anchors.

METHODS

A multicenter, retrospective review of all primary triceps repairs done between 2006 and 2015 was performed. Patients were included if they had a minimum of 2 years of follow-up. Intraoperative data recorded included repair method and number of anchors used when applicable. Patients were contacted for functional assessment with the Mayo Elbow Performance Score (MEPS). Postoperative complications were also queried.

RESULTS

There were 56 cases of primary triceps repair identified in an all-male cohort. Average age at time of surgery was 52.7 years; 58.9% of patients had transosseous repair, and 41.1% had suture anchor repair. The average follow-up was 4.26 years. The average postoperative MEPS score for all patients was 94. There was no difference in MEPS outcomes based on construct type. Postoperative Disabilities of the Arm, Shoulder, and Hand scores had an overall average of 4.81. A statistically significant difference was found, with the transosseous group averaging 2.98 points lower than the suture anchor group. This difference was not found to be clinically relevant. Only 4 patients had rerupture of the triceps requiring revision.

CONCLUSIONS

Primary repair of distal triceps tendon ruptures yields good, durable patient outcomes with minimal rerupture regardless of repair construct.

Triceps Tendon Ruptures: A Systematic Review

BACKGROUND

Triceps tendon ruptures (TTR) are an uncommon injury. The aim of this systematic review was to classify diagnostic signs, report outcomes and rerupture rates, and identify potential predisposing risk factors in all reported cases of surgical treated TTR.

METHODS

A literature search collecting surgical treated cases of TTR was performed, identifying 175 articles, 40 of which met inclusion criteria, accounting for 262 patients. Data were pooled and analyzed focusing on medical comorbidities, presence of a fleck fracture on the preoperative lateral elbow x-ray film (Dunn-Kusnezov Sign [DKS]), outcomes, and rerupture rates.

RESULTS

The average age of injury was 45.6 years. The average time from injury to day of surgery was 24 days while 10 patients had a delay in diagnosis of more than 1 month. Renal disease (10%) and anabolic steroid use (7%) were the 2 most common medical comorbidities. The DKS was present in 61% to 88% of cases on the lateral x-ray film. Postoperatively, 89% of patients returned to preinjury level of activity, and there was a 6% rerupture rate at an average follow-up of 34.6 months. The vast majority (81%) of the patients in this review underwent repair via suture fixation.

CONCLUSIONS

TTR is an uncommon injury. Risks factors for rupture include renal disease and anabolic steroid use. Lateral elbow radiographs should be scrutinized for the DKS in patients with extension weakness. Outcomes are excellent following repair, and rates of rerupture are low.

Triceps Ruptures After Fluoroquinolone Antibiotics: A Report of 2 Cases

Rupture of the triceps brachii tendon is exceedingly rare, and surgical repair is generally indicated. Fluoroquinolone antibiotics have been implicated in tendon pathology, including tendon ruptures. Triceps rupture has not been previously reported in the setting of fluoroquinolone antibiotic therapy. We present 2 cases of triceps tendon rupture after treatment with fluoroquinolones. In both cases, triceps repair was performed with good outcomes. These cases highlight a risk of fluoroquinolone-induced tendinopathy to athletes. The sports medicine team should be aware of this risk and consider it when choosing antibiotics to treat athletes.

A Comparative Biomechanical Analysis of 2 Double-Row, Distal Triceps Tendon Repairs

BACKGROUND

Triceps tendon ruptures are rare orthopaedic injuries that almost always require surgical repair. This study tests the biomechanical properties of an original anchorless double-row triceps repair against a previously reported knotless double-row repair.

HYPOTHESIS

The anchorless double-row triceps repair technique will yield similar biomechanical properties when compared with the knotless double-row repair technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen cadaver arms were randomized into 2 groups. One group received the anchorless repair and the other received the knotless anchor repair. A materials testing system (MTS) machine was used to cycle the repaired arms from 0° to 90° with a 2.5-pound weight for 1500 cycles at 0.25 Hz. Real-time displacement of the tendon was measured during cycling using a probe. Load to failure was performed after completion of cyclic loading.

RESULTS

The mean displacement with the anchorless technique was 0.77 mm (SD, 0.25 mm) at 0° (full elbow extension) and 0.76 mm (SD, 0.38 mm) at 90° (elbow flexion). The mean displacement with the anchored technique was 0.83 mm (SD, 0.57 mm) at 0° and 1.01 mm (SD, 0.62 mm) at 90°. There was no statistically significant difference for tendon displacement at 0º (P = .75) or 90º (P = .31). The mean load to failure with the anchorless technique was 618.9 N (SD, 185.6 N), while it was 560.5 N (SD, 154.1 N) with the anchored technique, again with no statistically significant difference (P = .28).

CONCLUSION

Our anchorless double-row triceps repair technique yields comparable biomechanical properties to previously described double-row triceps tendon repair techniques, with the added benefit of avoiding the cost of suture anchors.

CLINICAL RELEVANCE

This anchorless double-row triceps tendon repair can be considered as an acceptable alternative to a knotless anchor repair for triceps tendon ruptures.

Outcomes and complications of triceps tendon repair following acute rupture in American military personnel

INTRODUCTION

Triceps tendon ruptures are uncommon injuries primarily occurring in young, active males or elderly individuals with various systemic diseases. Relatively little is known about the epidemiology of this injury, or the results of surgical management in high-demand populations. The purpose of this study was to define the incidence and outcomes of surgical treatment in active duty American military personnel.

PATIENTS AND METHODS

The Military Data Repository (MDR) was queried for all active duty military personnel undergoing surgical repair or reconstruction of a triceps tendon rupture between January 2012 and December 2014. The electronic health records of all patients with at least 12 months clinical follow-up were searched for demographic information, injury details, preoperative imaging findings, post-operative complications, and ability to return to duty following surgical repair. Incidence was calculated based on total active duty population in the MDR over the study period. Risk factors for postoperative complication and inability to return to duty following surgical repair were assessed using univariate analyses.

RESULTS

A total of 54 acute triceps tendon ruptures were identified in the search, of which 48 had at least 12 months follow-up and complete post-operative records. The incidence of acute triceps tendon rupture was 1.1 per 100,000 person-years. Twelve patients experienced post-operative complications, six of which were traumatic re-ruptures within four months of the index surgery. No patient had a post-operative infection or atraumatic repair failure. 94% of patients were able to return to active military service following surgical repair. Enlisted rank was a significant risk factor for a post-operative complication, but no factor predicted inability to return to active duty service.

CONCLUSIONS

Surgical repair of acute triceps tendon ruptures reliably restores strength and function even in high-demand individuals. In our population, traumatic rerupture was the most common complication.